Dr. Rachel Rubin: What Doctors Won't Tell Women About Hormones, HRT, and Sexual Health
Dr. Rachel Rubin, a urologist and sexual health specialist, reveals how the medical system has catastrophically failed women by not training doctors in hormonal and sexual health. She explains hormone therapy, vaginal estrogen, clitoral anatomy, and the orgasm gap, showing that education, biology, and open communication are the most powerful tools available to women and their partners.
Overview
Dr. Rachel Rubin opens by declaring she is 'filled with rage' because women — including Melinda Gates, Oprah, and Halle Berry — are routinely denied adequate medical care for their hormonal and sexual health. A startling indicator of this gap: the word 'clitoris' does not appear in the official OBGYN training checklist as of 2026. Testosterone, widely misunderstood as a male hormone, actually begins declining in women in their 30s, affecting libido, arousal, and orgasm well before menopause.
The Women's Health Initiative study of the early 2000s was wildly misinterpreted, causing a collapse in HRT prescribing, and today only 1.7% of eligible women receive hormone therapy. Rubin introduces four categories of hormone therapy: systemic estrogen, systemic progesterone, testosterone, and local vaginal hormones. Vaginal estradiol cream (as low as $14) applied twice weekly prevents UTIs by more than 50%, resolves dryness and pain, and improves arousal and orgasm — and is safe for women of any age, including cancer survivors.
About 23% of women have clitoral adhesions, a simple, treatable condition that, when resolved, improves orgasm and satisfaction by 60-70%. The episode closes with a frank discussion of the orgasm gap, pornography's distorting effects, spontaneous versus responsive arousal, and the argument that education and communication are the true foundations of lasting sexual health.
Key quotes
5I am filled with rage because people are limiting their ability to have great sex, great relationships, and great health because they aren't having access to all the information that they could.
The word clitoris today in 2026 does not exist in the checklist for what an OB/GYN has to learn in their training. The word doesn't exist.
Only 1.7% of women who should be offered prescriptions are getting hormone therapy. It is a disaster.
What other organ in medicine do we let fail completely before we do something about it? We don't make you go blind completely before we give you eyeglasses.
We're in a sex recession. People are having less sex than ever. People are not connecting, people are scrolling and they're on their AI chatbots instead of human connection.
Key ideas
9Even the most privileged women are failed
Melinda Gates needed three doctors to obtain proper HRT. Oprah saw five doctors who missed that her heart palpitations were perimenopause-related. Halle Berry was misdiagnosed with genital herpes when she had genitourinary syndrome of menopause. This is a systemic failure, not a matter of individual access.
Clitoris absent from official OBGYN training
As of 2026, the word 'clitoris' does not appear in the official training checklist for OBGYNs. Gynecologists receive no mandatory training on clitoral anatomy, sexual pain, libido, or arousal — a foundational gap with cascading consequences for women's health care.
Testosterone is not a male hormone — and it drops in your 30s
Women produce and depend on testosterone for libido, arousal, orgasm, and clitoral engorgement. Unlike estrogen, which crashes at menopause, testosterone declines steadily throughout a woman's 30s — often causing symptoms years before perimenopause is suspected.
Medications alter hormones in ways patients are never told
Combined oral contraceptives suppress all ovarian hormone production, including testosterone, and up to 27% of users report reduced libido. GLP-1 drugs (Ozempic, Mounjaro) show sexual side effects in roughly 25% of women surveyed — research on this is almost entirely absent from the published literature.
The Women's Health Initiative study was catastrophically misread
A 2002 press conference incorrectly declared HRT caused cardiovascular disease and breast cancer, collapsing a multi-billion dollar industry overnight. The same study's authors published new analysis in 2025 confirming that below age 70, that type of HRT carries no increased cardiovascular or stroke risk.
Four buckets of hormone therapy — not one-size-fits-all
Rubin organizes HRT into four categories: systemic estrogen (hot flashes, bone health, sleep), systemic progesterone (uterine protection, sleep, anxiety), testosterone (libido, arousal, cognition), and local vaginal hormones (dryness, UTI prevention, sexual pain). Each woman may need one, some, or all four.
Vaginal estrogen is the most underused, safest intervention in women's health
A $14 generic estradiol cream or DHEA insert applied vaginally twice weekly reduces UTIs by more than 50%, eliminates dryness and pain, and improves arousal and orgasm. It is safe for women of any age and any medical history — including cancer survivors. Over 75% of women who need it are not receiving prescriptions.
One in four women has a clitoral adhesion — and no one is checking
In about 23% of women, the clitoral hood adheres to the head of the clitoris, reducing sensitivity. A simple in-office procedure to release the adhesion has been shown to improve orgasm, arousal, and sexual satisfaction by 60-70%. Standard gynecological exams never include a clitoral exam.
Spontaneous vs. responsive arousal explains many relationship misunderstandings
About 70% of men experience spontaneous arousal; in women this rate is only 10-15%. Approximately 40-50% of women are primarily responsive, meaning arousal develops once a sexual encounter begins. When partners interpret low spontaneous desire as rejection or low libido, relationships suffer unnecessarily.
Practical takeaways
7- 1
Ask about vaginal estradiol for UTIs, dryness, and pain 31:17
Vaginal estradiol cream (generic, as low as $14 at cost-transparent pharmacies) applied twice weekly is safe at any age and any medical history. It prevents UTIs by over 50% and resolves dryness, pain, and poor arousal.
- 2
Investigate testosterone if libido faded in your 30s 19:00
If libido has dropped, orgasms have weakened, or arousal feels blunted, ask a knowledgeable physician about testosterone levels. Women's testosterone declines through the 30s — long before menopause — and targeted supplementation can help.
- 3
Know how your contraception or medication affects your hormones 15:00
Combined oral contraceptives suppress ovarian hormone production including testosterone. If libido dropped after starting the pill or a new medication, discuss hormone-friendly alternatives with an informed provider.
- 4
Seek a specialist who actually examines the clitoris 58:51
Request a sexual medicine specialist or pelvic health urologist who performs a complete vulvar and clitoral exam. Roughly one in four women has a treatable clitoral adhesion that standard exams miss entirely.
- 5
See a pelvic floor physiotherapist if sex is painful 52:56
Tight or poorly coordinated pelvic floor muscles are a major, correctable cause of painful penetration and weak orgasm. A trained pelvic floor physiotherapist can assess and treat this without surgery.
- 6
Talk about sex outside the bedroom, not during it 1:20:38
Discuss preferences, what feels good, and what you want when you are not in the middle of a sexual encounter. Ask your partner: what does great sex mean to you? This removes performance pressure and opens genuine communication.
- 7
Schedule quarterly partner dates to protect intimacy 1:31:09
Block one day per quarter solely for connection with your partner — a walk, a bath, a meal together, free of children and work. Consistent investment in each other builds the trust and desire that sustains long-term intimacy.
Topics & chapters
14Opening: filled with rage at a broken system
Dr. Rubin introduces herself through her anger: women are denied access to evidence-based hormonal and sexual health care, and the doctors they see are not trained to help them.
Famous cases — even affluent women are failed
Melinda Gates, Oprah, and Halle Berry all received wrong diagnoses or had to see multiple doctors for basic hormonal care, illustrating a systemic rather than individual failure.
How HRT became a lost art
Doctors were never trained in hormone therapy, and a misinterpreted 2002 study terrified an entire generation of physicians out of prescribing it.
Hormones 101: the menstrual cycle, estrogen, progesterone, and testosterone
A plain-language explanation of how the three key hormones cycle each month, why testosterone drops in the 30s, and how hormonal changes affect the entire body — not just reproduction.
Medications that alter sexual health: the pill and GLP-1s
Combined oral contraceptives suppress all ovarian hormones; GLP-1 weight-loss drugs affect sexual function in roughly 25% of women — but no one is studying or disclosing this.
Hormone changes through life stages: puberty to post-menopause
From first periods to lactation to perimenopause, Dr. Rubin maps how hormonal shifts at every stage create symptoms that are treatable but rarely identified or addressed.
The Women's Health Initiative myth debunked
A 2002 press conference wrongly linked HRT to breast cancer and heart disease, causing prescribing to collapse. The study's own authors corrected the record in 2025; only 1.7% of eligible women currently receive HRT.
Four buckets of hormone therapy
Systemic estrogen, systemic progesterone, testosterone, and local vaginal hormones are the four categories — each with distinct indications, forms, and safety profiles.
Vaginal estradiol: the $14 cream that prevents death from UTIs
Dr. Rubin demonstrates vaginal estradiol cream and alternatives (tablet insert, ring, DHEA/Intrarosa) that applied twice weekly reduce UTIs by over 50% and restore sexual function — safe at any age.
Pain during sex: causes, diagnosis, and who to see
Up to 75% of women experience painful sex at some point. Causes include hormonal changes, skin conditions, tight pelvic floor muscles, nerve compression, and endometriosis — each requiring specialist diagnosis.
The orgasm gap, clitoral anatomy, and clitoral adhesions
Most women orgasm through clitoral stimulation, not penetration. About 23% have a clitoral adhesion; releasing it in-office improves orgasm and arousal by 60-70%. No standard exam currently checks for this.
What men get wrong and the distorting effect of pornography
Male performance metrics are irrelevant to female pleasure. Pornography, designed for male viewers, has created false expectations in both sexes about how women experience arousal and orgasm.
Arousal types, scheduling sex, and responsive desire
Women are predominantly responsive rather than spontaneous in arousal. Scheduling intimacy — including quarterly partner days — counters modern over-scheduling and sustains desire in long-term relationships.
Lifestyle blockers, body image, and the sex recession
Burnout, poor sleep, chronic stress, and negative body image all suppress desire. Rubin argues education and communication — not quick fixes — are the only lasting remedies to society's 'sex recession.'